Stroke Transfer Checklist When preparing to transfer an acute stroke patient to the UF Health Shands Comprehensive Stroke Center, please make every attempt to include the following information: Results of all diagnostic testing performed, including lab results and imaging exams. All imaging exams transferred to CD whenever possible. NIH stroke scale documentation to assess improvement or decline upon arrival to UF Health Shands Comprehensive Stroke Center. Time of symptom onset, or last time known well, and source of this information. Contact information of family members. (Cell phone if available.) Pertinent elements of patient past medical history. Especially atrial fibrillation, warfarin therapy, congestive heart failure, prior strokes, prior intracerebral hemorrhage, recent surgeries or instrumentation and trauma. Patient s current medications. Brief documentation of ALL therapies initiated at your hospital. If IV tpa is excluded, please document rationale. In no circumstances should acquisition of these items delay the transfer of the patient. URGENT TRANSFER MINIMIZING TIME TO PRESENTATION IS AN ABSOLUTE PRIORITY. 7/14/15 PS119177A1
NIH Stroke Scale CATEGORY DESCRIPTION SCORE ADMIT SCORE 1. Level of Consciousness Alert 0 (Alert, drowsy, etc.) Drowsy 1 Stuporous 2 Coma 3 a. LOC Questions Answers both correctly 0 (Month, age) Answers one correctly 1 Incorrect 2 b. LOC Commands Obeys both correctly 0 (Open, close eyes; squeeze and let go) Obeys one correctly 1 Incorrect 2 2. Best Gaze Normal 0 (Eyes open; patient follows examiner s fingers, face) Partial gaze palsy 1 Forced deviation 2 3. Visual No visual loss 0 (Introduce visual stimulus of threat to patient s visual field Partial hemianopia 1 quadrants) Complete hemianopia 2 Bilateral hemianopia 3 4. Facial Palsy Normal 0 (Show teeth, raise eyebrows and squeeze eyes shut) Minor 1 Partial 2 Complete 3 5. Motor Arm (Elevate extremity to 90 and score drift movement within 10 ) a. Left Arm 0 No Drift 1 Drift 2 Some effort against gravity 3 No effort against gravity 4 No movement b. Right Arm Amputation, joint fusion 0 (explain) 1 2 3 4 6. Motor Leg (Elevate extremity to 30 and score drift movement within 5 ) a. Left Leg 0 No Drift 1 Drift 2 Some effort against gravity 3 No effort against gravity 4 No movement b. Right Leg Amputation, joint fusion 0 (explain) 1 2 3 4 7. Limb Ataxia Absent 0 (Finger-nose, heel down shin) Present in one limb 1 Present in two limbs 2 8. Sensory Normal 0 (Pin prick to face, arm (trunk) and leg, compare side to side) Partial loss 1 Severe loss 2 9. Best Language No aphasia 0 (Name items, describe a picture and read sentences) Mild to moderate aphasia 1 Severe aphasia 2 Mute 3 10. Dysarthria Normal 0 (Evaluate speech clarity by patient s repeating listed words) Mild to moderate aphasia 1 Near to unintelligible or worse 2 Intubated or other physical barrier 9 11. Extinction and inattention No neglect 0 (Use information on prior testing to identify neglect or double Partial neglect 1 simultaneous stimuli) Complete neglect 2 SCORE TOTALS MD Signature MD # Date Time 7/14/15 PS119177A2
tpa Protocol Checklist Yes No Inclusion criteria h h 1. Stroke onset within 4.5 hours of initiation of IV tpa deficit not improving h h 2. Patient over 18 years of age h h 3. Clinical diagnosis of ischemic stroke; CT excludes hemorrhage h h 4. Deficit sufficient to justify risk of tpa h h 5. Patient consents to use of tpa Yes No Exclusion criteria h h 1. Current intracranial hemorrhage h h 2. Subarachnoid hemorrhage h h 3. Active internal bleeding h h 4. Recent (within 3 months) intracranial or intraspinal surgery or serious head trauma h h 5. Presence of intracranial conditions that may increase the risk of bleeding h h 6. Platelet count less than 100,000 h h 7. INR over 1.7 h h 8. Current severe, uncontrolled hypertension: systolic greater than 185; diastolic greater than 110 Yes No Other considerations h h 1. Age over 80 years h h 2. CT evidence of early edema, mass effect or large infarct (especially if over 1/3 MCA territory) h h 3. NIH Stroke Scale over 20, severe stroke with coma, severe obtundation, complete hemiplegia In no circumstances should acquisition of these items delay the transfer of the patient. URGENT TRANSFER MINIMIZING TIME TO PRESENTATION IS AN ABSOLUTE PRIORITY. 7/14/15 PS119177A3
tpa Quick Reference Sheet Estimated Weight (lbs) Conversion to Kilograms (kg) Total IV tpa Dose (mg) at 0.9 mg/kg tpa Bolus (mg) *10% of Total* tpa Bolus (ml) Discard Dose tpa (not for infusion) Infusion Dose (mg) Infusion Rate (ml/hr) 1. Obtain patient weight. 2. Verify inclusion/exclusion criteria and discuss plan with patient and/or family. Obtain consent if possible. Do not delay treatment in absence of consent. 3. Verify that administration will start within 4.5 hours of symptom onset or time last known well. 4. Verify SBP < 185; DBP < 110 220+ 100 90 9 9 10 81 81 210 95.5 86 8.6 8.6 14 77.4 77.4 200 90.9 81.8 8.2 8.2 18.2 73.6 73.6 190 86.4 77.8 7.8 7.8 22.2 70 70 180 81.8 73.6 7.4 7.4 26.4 66.2 66.2 170 77.3 69.6 7 7 30.4 62.6 62.6 160 72.7 65.4 6.5 6.5 34.6 58.9 58.9 150 68.2 61.4 6.1 6.1 38.6 55.3 55.3 140 63.6 57.2 5.7 5.7 42.8 51.2 51.2 130 59.1 53.2 5.3 5.3 46.8 47.9 47.9 120 54.5 49.1 4.9 4.9 50.9 44.2 44.2 110 50 45 4.5 4.5 55 40.5 40.5 100 45.5 41 4.1 4.1 59 36.9 36.9 5. Usual dosage range and route: 0.9 mg/kg to a maximum of 90 mg First 10% of calculated dose as intravenous bolus dose Remaining 90% of calculated dose given as infusion over 1 hour 6. Document neurologic assessment findings at least hourly or more frequently if neurologic changes occur. 7. If the patient s neurologic status declines during tpa infusion the following actions should be taken: Stop the infusion Draw and send PT/PTT Obtain emergent CT In no circumstances should acquisition of these items delay the transfer of the patient. URGENT TRANSFER MINIMIZING TIME TO PRESENTATION IS AN ABSOLUTE PRIORITY. 7/14/15 PS119177A4
Stroke Post-tPA Ambulance Transfer Orders tpa dosing and administration communication: This page is to be completed by ED RN and medical transport team, as applicable. Verify/confirm the following dosing and pump settings prior to departure. Patient wt: kg Total tpa dose to be given: mg Excess tpa discarded after mixing and before hanging on pump: Yes: mg No, excess still in bottle/bag Bolus dose: mg Time given: Continuous Infusion: Dose: mg Time started: Rate: mg/hr Estimated time of completion: Actual stopped/completed time: Stopped early due to: Total amount tpa received: mg (Ensure that all tpa in IV tubing is administered.) ED RN Initials Medical Transport Initials Signature/Title Initials Signature/Title Initials Medical transport team to hand off this completed communication form to RN at receiving facility upon arrival. 7/14/15 PS119177A5
Stroke Post-tPA Ambulance Transfer Orders Date / / Month Day Year Time Transfer patient to Dr. has agreed to assume care. Patient to be transported with Adult Life Support or Critical Care Transport with the following instructions: Prior to departure: 1. Verify that systolic blood pressure is less than 180; diastolic less than 105. If BP above these limits, sending hospital should stabilize prior to transport. 2. Obtain contact method for family or caregiver (preferably cell phone) to allow contact during transport or upon patient arrival. 3. Perform and document initial neurological exam to establish baseline neurological status. 4. If tpa to continue during transport, review/verify tpa dosage and IV pump settings with transferring RN: a. Complete the tpa Dosing and Administration Communication form in this packet. 5. If the IV pump tubing used in the ED is not compatible with the pump used for transport, discuss the plan for pump and/or tubing change that will accommodate safe administration of the full and correct tpa dose, including the amount in the tubing. a. Adding an extension tubing set with a cartridge adaptable to the transport pump (such as a half-set ) may be a viable option, if available. b. If unable to accommodate administration of the full tpa dose enroute, hold patient in the ED until tpa infusion is completed. During transport: 1. When the tpa bottle is empty, and before the pump alarms air in line, replace the tpa bottle with a bag of 0.9% Sodium Chloride. Continue the infusion at the current settings on the pump until the preset volume is completed. This will ensure that the patient safely receives the full amount of tpa in the tubing. 2. Continuous cardiac monitoring and pulse oximetry. 3. O 2 per nasal cannula and titrate to maintain oxygen saturation at 94%. 4. Maintain NPO including medications. 5. Perform and record neuro checks every 15 minutes. a. Cincinnati Stroke Scale (or other stroke scale) recommended. Include assessment for changes in initial or current symptoms or onset of new stroke-like symptoms. b. GCS and pupil exam. 6. Monitor and document vital signs every 15 minutes. 7. Use manual BP cuff if possible when using arm with antecubital IV site. 8. Maintain head of bed 25-30 degrees less if tolerated. (continued on next page) 7/14/15 PS119177A6
Stroke Post-tPA Ambulance Transfer Orders Blood pressure management: Keep SBP less than 180 and DBP less than 105: h IV Nicardipine (0.1mg/mL) infusion: Increase Nicardipine by 2.5mg/hour every 5 minutes (to a maximum of 15mg/hour) until SBP is less than 180 and/or DBP is less than 105. If SBP is less than 140, or DBP is less than 80, turn off drip and call medical control for further instructions. h Labetalol injection 10mg IV over 1-2 minutes, may repeat every 10 minutes as needed (maximum dose 300mg). Hold for HR < 50. h Other: Contact medical control for further orders if unable to manage SBP <180 and DBP < 105 using above medications. Complication management: 1. Monitor for signs of intracranial hemorrhage (ICH) : acute worsening of neurological status as compared to baseline neuro-assessment or Glasgow Coma Scale, sudden onset of headache, nausea and/or vomiting, sudden elevation in blood pressure and/or bradycardia. If signs of ICH present: Stop tpa if still infusing Call medical control for further instructions Continue to monitor and document VS and neuro exam every 15 minutes Contact the receiving ED with update and ETA 2. Monitor for signs of angioedema (mouth or throat edema, difficulty breathing). If signs present: Stop tpa Treat according to allergic reaction protocol Notify medical control 3. Monitor for other bleeding or hematomas (infusion/puncture sites, urine, emesis). If bleeding present, apply direct pressure to any sites and notify medical control. Additional instructions: h h h Physician Signature/Title Date Time 7/14/15 PS119177A7